Page 5

BAM 110 5 of 28 APPLICATION FILING AND REGISTRATION BPB 2025-003 1-1-2025

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

• Title IV-E recipients; see BEM 117. • Special Needs Adoption Assistance Agreement recipients; see BEM 117. • Newborns of MA beneficiaries; see BEM 145. Retro MA Applications Medicaid Only The DHS-3243, Retroactive Medicaid Application, is used along with the DHS-4574 for retro MA applications. Only one DHS-3243 is needed to apply for one, two or three retro MA months; see Retro MA Applications in BAM 115. When the request for retroactive Medicaid coverage, including specific months, is indicated on the DCH-1426, MDHHS-1171 HCC, Supplement Healthcare Coverage, FFM application, or MI Bridges, a separate DHS-3243 is not required. Who May Apply All Programs Any person, regardless of age, or their authorized representative (AR) may apply for assistance. For FAP only, an AR must apply on behalf of certain clients; see the Authorized Representatives section in this item. Date of Application All Programs Paper Applications The date of application is the date the local office receives the required minimum information on an application or the filing form. Record the date of application on the application or filing form. The date of application does not change when the application is transferred to another local or district office. FAP Only See the Where To Apply/Process Applications / section in this item.

loading…

Page 5

Official source

BAM 110 5 of 28 APPLICATION FILING AND REGISTRATION BPB 2025-003 1-1-2025

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

• Title IV-E recipients; see BEM 117. • Special Needs Adoption Assistance Agreement recipients; see BEM 117. • Newborns of MA beneficiaries; see BEM 145. Retro MA Applications Medicaid Only The DHS-3243, Retroactive Medicaid Application, is used along with the DHS-4574 for retro MA applications. Only one DHS-3243 is needed to apply for one, two or three retro MA months; see Retro MA Applications in BAM 115. When the request for retroactive Medicaid coverage, including specific months, is indicated on the DCH-1426, MDHHS-1171 HCC, Supplement Healthcare Coverage, FFM application, or MI Bridges, a separate DHS-3243 is not required. Who May Apply All Programs Any person, regardless of age, or their authorized representative (AR) may apply for assistance. For FAP only, an AR must apply on behalf of certain clients; see the Authorized Representatives section in this item. Date of Application All Programs Paper Applications The date of application is the date the local office receives the required minimum information on an application or the filing form. Record the date of application on the application or filing form. The date of application does not change when the application is transferred to another local or district office. FAP Only See the Where To Apply/Process Applications / section in this item.